The Cross Keys Practice Travel Vaccination Request Form

·  Please complete a separate Travel Vaccination request form for each individual traveller.

·  Where possible complete this form at least 8 weeks before your departure date as some vaccinations require more than one dose and can take 4 weeks to give full protection.

·  A Travel Vaccination appointment can be made when you send/ drop off your form. Or alternatively you can ring a week later to find out what has been recommended.

·  If less than two weeks notice is given it is unlikely we will be able to offer an appointment.

·  We also process Travel Vaccination requests through our website: www.crosskeyspractice.co.uk

·  Please note that no vaccine offers 100% protection and a small proportion of individuals get infected despite vaccination.

Surname: / Forename: / Date of Birth:
Departure Date: / Length of stay: / Telephone number:
Countries to be visited including stopovers:
Special considerations: e.g. backpacker, safari, rural areas to be visited, school trip, aid worker:
Are you pregnant, breast feeding or planning a pregnancy?
Do You Smoke? Y / N Daily Amount:-
Please record any allergies (drugs/food)
Are you undergoing chemotherapy/radiotherapy or have you in the past 6 months?

There is a charge for some vaccines and private prescriptions.

Prices are per dose.

Hepatitis B £44 (primary course is 3 doses) Rabies £75 (primary course is 3 doses) Japanese encephalitis £125 (primary course is 2 doses) Yellow fever £75

Meningitis ACWY £68

Private prescriptions £5 PTO

Please enter dates of the vaccinations you have received. This is particularly useful if you have had vaccinations outside general practice, such as at school or work.

NB If you are an unregistered patient you can have travel immunisations as a temporary patient. For this you need to fill in a temporary resident form and ask the surgery where you are registered to email your immunisations to or fax to 01844 271606

Diphtheria / Tetanus / Polio
Hepatitis A
1
2 / Yellow Fever / Typhoid
Hepatitis B
1
2
3 / Rabies
1
2
3 / Meningitis C
Meningitis A&C
Meningitis ACWY
Japanese Encephalitis / Tick borne encephalitis / Other

For completion by Surgery Administration only:

Date Received / Date processed

IMMUNISATIONS RECOMMENDED

(R=strongly recommended S=sometimes recommended)

Diphtheria /Tetanus/Polio
Hepatitis A / Yellow Fever / Typhoid
Hepatitis B / Rabies / Meningitis ACWY
Japanese encephalitis / Tick borne encephalitis / Cholera

MALARIA CHEMOPROPHYLAXIS

Advice only / Chloroquine / Paludrine
Mefloquine (Larium) / Malarone / Doxycycline

GP AUTHORISATION FOR VACCINES

GP signature: / Date: